Wednesday, July 13, 2011

Revision surgery for failed total shoulder replacement arthroplasty

When a shoulder replacement fails to result in satisfactory restoration of comfort and function, the surgeon and the patient are challenged to determine the most likely causes and how the failure can be best managed. It is always important to keep in mind the wide range of potential causes of joint replacement failure. These have been well characterized by our shoulder fellows Hasan and Franta

While pain is often a presenting complaint, we try to determine as well if the shoulder is stiff, unstable, weak or crepitant, in that each of these mechanical characteristics provides clues to what may be going on with the joint. For example a shoulder arthroplasty may be stiff because of adhesions (scar), blocking osteophytes (bone spurs), or overstuffing (too large prosthetic components). Weakness may result from rotator cuff failure, subscapularis detachment, nerve injury, deltoid detachment, or disuse atrophy of the muscles. Instability may result from suboptimal positioning of the components, component loosening or soft tissue imbalance. Crepitation, clicking, or clunking may result from component loosening, soft tissue ingrowth, loose bodies within the joint or joint surface irregularities.

As pointed out by Hasan and Franta infection is an ever present concern in painful shoulder arthroplasties. Trying to better understand the causes, prevention, diagnosis and treatment of shoulder joint replacement infections has become a major interest of mine. Stay tuned on this blog for some of our late-breaking discoveries. For now, suffice it to say that shoulder infections most often present themselves only by shoulder pain - the 'traditional' evidences of infection, such as fever, chills, redness, swelling, elevated while blood cell count, elevated sedimentation rate, and elevated C reactive protein are usually absent.

So a thorough evaluation of the patient and the shoulder are essential before considering the best treatment. A careful history is needed to determine the original diagnosis, the initial result of the joint replacement, the onset of discomfort or loss of function, any injuries, dental or other procedures that may have introduced infection, and any intercurrent diseases. The physical exam must seek evidence of stiffness, weakness, instability or crepitance. Finally, high quality x-rays are needed to look for the position and relationship of the prosthetic components as well as evidence of loosening or wear of these components.

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